MODULE nine short answer questions.

saq 1.

A 40 year old male attends your emergency department after a fight in a bar 15 minutes previously. He is complaining of left jaw pain and a missing front tooth which the ambulance have transported to you under the patient’s tongue. He did not lose consciousness, has a full memory of the event, and there are no other concerns for a closed head injury.

His vital signs are

HR 89 /minBP 119/78 mmHgRR 18 /minSats 98% RAT 36.9

Question 1.

An OPG is shown below. What are the two major abnormalities? (2 marks)

Must include:-undisplaced fracture of the left mandibular condyle-absent/avulsed front left incisor

Question 2.

Give 8 steps will you take in managing the avulsed tooth? (8 marks)

Answer (mandatory steps in bold (1 mark per step)

1.Handle avulsed tooth by crown only/do not touch root2.Provide appropriate analgesia and or dental block3.Rinse root of tooth with normal saline4.Gently irrigate socket with normal saline5.Reimplant tooth into socket6.Stabilise with dental mould7.Administer ADT if required8.Refer to a dentist urgently for follow up

saq 2.

​A 45 year old construction worker presents to your department after being hit in the left face with a falling brick. He has no loss of consciousness, and no symptoms of closed head injury. He has a swollen painful left eye.

His vital signs are:

HR 99 /minBP 123/88 mmHgRR 16 /minSats 99% RAT 37.1 oC

Question 1.

A CT of the patient’s face is shown below. Give 4 major abnormalities? (4 marks)

Must include

1.Fracture through frontozygomatic suture2.Fracture through floor of orbit3.Fracture through lateral wall maxillary sinus4. Blood in left maxillary sinus

Question 2. (2 marks)

What other fracture is likely to be present but not seen on the above image? What is the name given to this complex of fractures?

saq 3.

A 24 year old man is brought to the emergency department after a high speed MVA. His primary survey does not reveal any evidence of acute airway compromise or chest injury and an e-FAST ultrasound of the chest reveals no pneumothorax.

His vital signs are:

HR 110 /minBP 93/67 mmHgRR 24 /minSats 99% 6LT 36.7 oC

GCS 6 (E1 V1 M4)

Question 1. (6 marks)

Using the table below outline 3 important principles of your intubation of this patient and state how you will apply them to this patient.

PRINCIPLE

1. Prevention of secondary neurologic injury

​2. Prevention of secondary c-spine injury

3. Optimized intubation/"1st attempt is the best attempt"

PRACTICE

1. Prevention of hypoxia/hyptension during intubation

​2. Manual in line stabilisation during intubation

3. Use of adjuncts (bougie/stylet), experienced operator

The patient is successfully intubated and transferred to the CT scanner. A clinical image is produced below.

CANADIAN-dangerous mechanism (fall down >5 stairs)-neck pain at scene-neck pain during palpation-numbness or tingling in extremities

Question 2.

The patient complains of left arm numbness and pain in her mid to lower c-spine on palpation. Will you perform an xray or CT of her c-spine and why? (2 marks)

Must include (1 mark for CT, 1 mark for reasonable explanation):-CT of the C spine. This patient has two indications for scanning, and thus should have a test of appropriate sensitivity (ie a CT).

Question 3.

An image of the c-spine is shown below. What give 2 major abnormalities and the diagnosis?

Must include (1 mark each):>50% anterior displacement of C6 on C7anteriorly displaced fracture of the body of C7

This is a diagnosis of bilateral facet joint dislocation (2 marks)

saq 5. (follows into saq 6)

A 30 year old man is brought to the emergency department with neck pain after a sporting injury. He had been fielding at silly point whilst playing cricket, and has been struck in the anterior neck over the adam’s apple by a cricket bat.

Question 1.

What will you assess for with regards to a laryngeal fracture? (5 marks)

Must include:- stridor-voice changes/hoarseness-pain with laryngeal palpation-bruising/swelling/loss of laryngeal landmarks-crepitus/surgical emphysema over larynx

Question 2.The patient has clinical evidence of a laryngeal fracture and a decision is made to intubate. Describe your procedure for a surgical airway in the event of not being able to intubate or oxygenate the patient.Must include:

1.Landmark is cricothyroid membrane.2.Scalpel used to divide skin and puncture membrane3.Insertion of mosquito forceps or finger into opening4.Insertion of bougie5.Size 6.0 ETT placed over bougie into trachea and secured6.confirmation of ventilation with capnography

SAQ 6. (Follows on from saq 5.)

You successfully achieve a surgical airway. Once the tube is placed and confirmed by waveform capnography you notice that there is an abundance of pink frothy sputum accumulating near the filter.

An arterial gas taken immediately is shown below.

FiO2 60%

pH 7.21pCO2 69 mmHgpO2 110 mmHgHCO3- 27 mmol/L

Na+ 140 mmol/LK+ 4.5 mmol/LCl- 110 mmol/L

Question 1. (2 marks)

Give two acid base disturbances present.

1. Respiratory acidosis2. Metabolic compensation/alkalosis

Question 2. (2 marks)

What is the likely diagnosis? Perform a calculation to support your answer.